TABLE OF CONTENTS
SPECIAL PLAN PROVISIONS UNDER THE SHBP
Women’s Health and Cancer Rights Act
Work-Related Injury or Disease
Health Insurance Portability and Accountability Act
Mental Health Parity Act Requirements
Purchase of Individual Insurance Coverage
Medical Plan Extension of Benefits
STATE HEALTH BENEFITS PROGRAM ELIGIBILITY
Medicare Coverage While Employed
Eligible Dependents of Retirees
Enrolling in the Retired Group of the SHBP
How to File a Claim If You Are Medicare Eligible
Retirees With Medicare Who Move Outside the United States
Continuing Coverage When It Would Normally End
Employer Responsibilities Under COBRA
Employee Responsibilities Under COBRA
Failure to Elect COBRA Coverage
How to Determine Available Benefits
GENERAL CONDITIONS OF THE PLAN
Medical Need and Appropriate Level of Care
Reasonable and Customary Allowances
Experimental or Investigational Treatments
Educational or Developmental Services or Supplies, or Educational Testing
Custodial, Maintenance, and Supportive Care
Employee Prescription Drug Plan
Prescription Drug Benefits Provided Through SHBP Health Plans
Employee Prescription Drug Reimbursement Plan for Traditional Plan Members
Retiree Prescription Drug Coverage
Alcohol and Substance Abuse Benefits - Inpatient
Eligible Services and Supplies
Other Services Paid Under Basic Benefits
Home Health Care Agency Benefits
Mental Health Benefits - Inpatient
Obstetrical Care Benefits - Inpatient
Surgical Centers/Ophthalmic Surgical Centers
Eligible Services and Supplies
Alcohol and Substance Abuse Treatment
Diabetic Self-Management Education
Hospital-Based Weight Loss Programs
Lyme Disease Intravenous Antibiotic Therapy
Patient Controlled Analgesia (PCA)
Temporomandibular Joint Disorder (TMJ) and Mouth Conditions
CHARGES NOT COVERED BY THE PLAN
Filing Deadlines - Proof of Loss
Medicare Claims and Other Coverage
APPENDIX I — Summary Schedule of Services and Supplies
Basic (Hospitalization) Benefits
Extended Basic (Medical-Surgical) Benefits
APPENDIX II — Claim Appeal Procedures
Appendix III — SHBP Medical Treatment Policies
Lyme Disease Intravenous Antibiotic Therapy
Early Disseminated Lyme Disease
Late/Chronic Disease Lyme Arthritis and Late/Chronic Disease Neuroborreliosis
APPENDIX V — SHBP Notice of Privacy Practices